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Medicaid

As a loyal Bostonian, I don't seem to tire of all the talk of health reform efforts in Massachusetts and enjoy noting our successes. We've gone from a 10.3 percent uninsurance rate before reform, to covering over 97 percent just less than two years later. But passing a law and creating new insurance structures is only part of our success. Massachusetts not only built it -- it figured out how to make people come.

After all the sound and fury of last August, we're pleasantly surprised that the right hasn't risen again with all sorts of horror stories about the resurrection, so to speak, of the "death panels." Maybe because all that fear-mongering was finally discredited. Maybe we are finally getting just a little bit smarter.

The inevitable focus on the politics of health reform, and the disproportionate amount of attention paid to the public plan, sometimes obscures the many ways that the House and the Senate health plans are ambitious. Not perfect. Ambitious. I've heard experts, people I like and respect, say the legislation does "nothing" to advance the cause of quality of end of life care in America. They are wrong. The House and Senate bill each contain measures that would advance that cause -- not fix it completely, far from it, but they will take us important steps in the right direction. It's too soon to know which of these measures - if any -- will survive a final melding of House and Senate legislation. But let's look at them here because, except for the end of life consults which got way too much of the wrong kind of attention, they haven't gotten adequate attention. In an accompanying guest post. Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center in New Hampshire, talks about what these changes can mean for his patients and their families.

In the world of state health reform, Vermont often plays the Jan to Massachusetts' Marcia. However, preliminary evaluations suggest that other states and policymakers would do well not to ignore New England's favorite middle child. My colleague previously wrote about Vermont's most recent legislative action on health reform passed in May of 2006. Now, a study published by the Robert Wood Johnson Foundation this week updates us on Vermont's achievements. Here are some of the successes from the Year 1 Interim Report:

We've written often about misaligned incentives in the US health care system -- we pay for quantity of care instead of paying for quality. We've seen high-performing health systems across the nation work to reverse this trend -- and succeed in bringing down costs and improving quality. It is possible for the U.S. health care system to become a value-based purchaser, to move toward pay for performance (healthier patients getting the right treatment at the right time) rather than fee for service (paying for more and more tests and procedures, regardless of whether or not they help the patient). So we're glad to see states taking steps toward pay for performance by including it in their Medicaid contracts.

As policymakers put the final touches on health care legislation that would expand coverage to millions of Americans, it is important that they ask themselves, "Coverage for what?"

Two new reports from the Georgetown University Health Policy Institute and the Kaiser Family Foundation tackle this question head on, looking at health coverage for children and individuals with special needs. Both groups require specialized care. The reports analyzed how insurance coverage differs between a benchmark private plan and public programs. Read the full reports, respectively, here and here.

We've written in the past about the North Carolina Medicaid Medical Home model, and its success in providing high quality care to vulnerable populations while saving money. The Kaiser Foundation's Drew Altman focuses on Community Care of North Carolina in his latest commentary. We aren't going to rehash the program here, (read our earlier posts or this Kaiser issue brief) but we were interested in what he identifies as the "few big messages to take away from this experience." The emphasis is ours:

Congress is back in session for what figures to be a frantic month of July. As the House and Senate gear up for a packed schedule of health reform hearings and mark-ups to meet a self-imposed August deadline, the White House has been working very hard to line up support outside the halls of Congress and keep the process moving.

First, there was the much-reported stakeholders' letter to the White House pledging to help slow health care spending by some $2 trillion over 10 years. Then, there was the $80 billion agreement with PhRMA—endorsed by the AARP—to lower costs of prescription drugs and help pay for reform. Just last week, the nation's largest employer, Wal-Mart, in a letter to the president also signed by SEIU and the Center for American Progress, stated that it was open to an employer mandate as part of the shared responsiblity it and other businesses bore for health reform.

Here's the last of our posts this week on health reform history...Then we'll turn our attention back to health reform's future...

Medicare, the government health insurance system that covers all America's senior citizens and many of its disabled, and Medicaid, a federal-state partnership providing insurance to the poor, are two of the great legacies of the Great Society era of the mid-1960's. Medicare and Medicaid cover tens of millions of people and remain giants of the current American social contract. Like the State Children's Health Insurance Program of the mid 1990s, Medicare and Medicaid emerged after a comprehensive reform initiative had failed earlier.

In the 1940s, Congress and President Truman made various attempts to institute national health insurance. A 1947 bill with Republican support (including that of Congressman Richard Nixon) would provide government subsidies for a private nonprofit insurance system with premiums scaled to individual's incomes. (If you include private for-profit insurance companies in the mix, it sounds quite a bit like current coverage proposals.) In 1950, Congress did finally pass, and Truman signed, legislation to provide federal matching grants to state payments for medical care for the poor. This became the forerunner to Medicaid.

During the 1950s, expanding health coverate to all temporarily faded as a pressing political concern, reflecting both the enormous expansion of employer-sponsored insurance and the conservatism of the time. But by the late 1950s, pressure grew to expand Social Security to include relief from medical bills for the aged. Because the elderly have the highest medical costs of any group, many seniors were unable to purchase insurance; medical bills were a leading cause of poverty among the elderly. In 1960, outgoing President Eisenhower did sign into law Kerr-Mills, the forerunner to Medicare. That gave grants to states for health care for the aged poor. But it didn't work very well; by 1963, only 28 states were participating.

Though the massive Democratic sweep of 1964 gave President Johnson huge majorities in Congress. Medicare and Medicaid emerged from a compromise between the majority and the Republican minority in Congress.

In what's been hailed as the most significant health legislation in Colorado in some 40 years, Colorado has a new law that will help cover up to 100,000 uninsured people and reduce some of the uncompensated care and cost-shifting that hurts the state's health care system and raises costs for people who are insured. It's an impressive achievement in a time of great economic pressure—one that we hope the folks here in Washington notice.

"At no increased cost to taxpayers, the Colorado Healthcare Affordability Act will allow us to provide critical health services to people who need those services the most," Gov. Bill Ritter said in a statement when he signed it into law earlier this week.

The law needs to get final approval from federal Medicaid officials. The goal is to implement it next spring. Ritter said that the law will provide coverage to about 100,000 and improve access to hospital care for the other 700,000 uninsured. (Colorado had an estimated 800,000 uninsured in 2007, that figure may be rising because of the job losses of the recession.)